LB 



TREASURY DEPARTMENT 
UNITED STATES PUBLIC HEALTH SERVICE 

HUGH S. GUMMING, Surgeon General 



THE SCHOOL NURSE 



BY 



TALIAFERRO CLARK j ^47 

Surgeon 
United States Public Health Service 



REPRINT No. 783 

FROM THE 

PUBLIC HEALTH REPORTS 

September 8, 1922 
( Pages 2193-2205 ) 



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WASHINGTON 

GOVERNMENT PRINTING OFFICE 

1922 



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THE SCHOOL NURSE: HER DDTIES AND RESPONSIBILITIES.' 

By Taliaferro Clark, Surgeon, United States Public Health Service. 

The greatly specialized nursing service of the present time did not 
suddenly spring into existence, but has been of more or less gradual 
evolution. At no time throughout recorded history has the condition 
of the poor and helpless sick failed in appeal to the mercy and sym- 
pathy of special groups of individuals. The ancient Egyptians were 
not unmindful of the humanitarian duty to help them. Long before 
the Christian era the priests of Israel enjoined their charges "to 
visit the sick, in order to show sympathy, to cheer, aid, and relieve 
them in their suffering. " 

With the passing of the old order and the dawning of the new, this 
work was largely carried on by conventual orders. By the establish- 
ment of a training school for nurses in London in 1840, and the 
founding of the first district nursing association by William Rath- 
bone in 1859, the nursing movement received a distinct impetus, 
which has expanded to include the many forms of nursing service 
of the present day and generation. 

THE BEGINNING OF SCHOOL HEALTH SUPERVISION. 

Since it is impracticable to disassociate the school from the home in 
successful school health work, so, likewise, is it futile to attempt 
school medical service without considering the school nurse. To 
France belongs the honor of first beginning school health supervision 
in 1837, when this duty was imposed on the school authorities by 
royal ordinance. 

The first attempt at school health supervision in this country was 
made in Boston, Mass., in 1894, when school medical inspection was 
started for the control of communicable diseases. However, it was 
not until some years later that school nursing became a recognized 
institution in both this country and England. 

1 Originally published in Special Bulletin No. 210 (January, 1922), issued by the North Carolina State 
Board of Health, and printed here by permission Keprintfrom the Public Health Reports, vol. 37, No. 
36, Sept. 8, 1922, pp. 219.3-2205. 

12852—22 Q 



4 THE SCHOOL NUESE. 

THE GENERAL QUALIFICATIONS OF THE SCHOOL NURSE. 

It has been said that poets are born, not made. So it is with the 
most successful school nurse. Unless she has the background of a 
sound heredity, is tactful and of equable temperament, is herself in 
good health, and is imbued with a love and understanding of children, 
her work will be more difficult and less fruitful of results than other- 
wise would be the case. 

Training. — In addition to her regular training-school and hospital 
work, it is prefer^ible that the school nurse shall have had public- 
health nursing experience and some practical instruction in the 
essentials of nutrition and in the sanitary requirements of school 
buildings and grounds. In the present stage of development, or 
lack of development, of school hygiene in different States and com- 
munities, the school nurse should have a background of training and 
experience, which at first sight would seem not properly required of 
her. In any case, whether or not circumstances require of her 
the discharge of certain duties more properly the task of a school 
physician, the school nurse with such training and experience is the 
best possible aid to the school physician. 

PROPORTION OF PUPILS TO EACH SCHOOL NURSE. 

In general, school nurses should be assigned in the proportion of 
1 nurse to each 1,000 to 2,000 school children, varying with the 
density of population, the average number of children to the family, 
the size of the school district, and accessibility of the homes from the 
standpoint of distances to be traveled in proceeding from home to 
home in follow-up work. 

In rural districts the proportion of children to a nurse is usually 
much larger than is the case in cities, owing to the difficulty of securing 
adequate funds. This is unfortunate, because, on account of the long 
distance a nurse is required to travel in visiting rural homes, fewer 
children can be looked after in a given time and large numbers of 
children who, as a rule, are without special health supervision, are 
perforce denied these privileges. 

Finally, in a school health supervision system which includes 
special school clinics, additional nurses should be provided in the 
proportion of one nurse for each operator. 

Comhined school and routine health worTc. — In communities where 
the school nursing service is under the direction of the health authori- 
ties, the school nurse can be utilized with profit for combined school 
and health department work. In such case nurses should be 
assigned in proportion of 1 nurse to 500 school children. 

Unification of the duties of the school and public-health nur'^ing 
service in one system will be more economical and produce more 



THE SCHOOL NUESE, 5 

satisfactory results than is possible from the present usual practice. 
In many communities it is not uncommon for a single home to be 
visited in turn by a contagious-disease nurse, a nurse of the district 
nursing association, a tuberculosis nurse, a nutrition worker, and by 
representatives of a number of social agencies, greatly to the annoy- 
ance of the householder. In the vast majority of rural districts 
it will not be possible properly to cover the whole field of school 
nursing service, except by such combination, owing to the nearly 
universal lack of funds to carry out comprehensive and useful pro- 
grams separately. 

Supervising nurses. — Where three or more school nurses are 
employed, one of them should be designated as supervisor and held 
responsible for the proper conduct of the work. In large school 
systems, assistants to the supervising nurse should be employed in 
the proportion of approximately 1 assistant to every 10 nurses. 

Duties of the supervising nurse. — The supervising nurse is expected 
to plan and supervise the work of the school nurses. She should 
advise with the school medical and teaching staffs and systematize 
the school nursing service so as to obtain the best results from the 
work. She should be held responsible for the satisfactory discharge 
of their duties by individual workers, and be required to instruct 
them individually and collectively in routine school nursing and in 
the more specialized clinic and health education work. 

Duties of a School Nurse. 

The duties that may be expected of a school nurse will vary accord- 
ing to whether no school physician is employed, a physician is em- 
ployed on full-time or part-time basis, and whether her work is in a 
rural or urban school. 

A. WHEN A FULL-TIME PHYSICLA.N IS EMPLOYED. 

In schools where a physician is employed on full-time basis the 
nm^se's work should supplement that of the school physician and 
correlate with it. The school nurse should be directly responsible to 
the school physician for the proper discharge of her duties, which 
may be for routine or special work. 

1. Routine duties. — In any circumstance there are certain duties 
required of school nurses in general, irrespective of the type of school 
or character of the medical assistance. Briefly, these are as follows : 

(a) Daily inspection, instruction, and disposition, usually in the 
morning, in a room set aside for the purpose, of children referred by 
the school physician or members of the teaching staff, who are sick 
with some communicable disease, suffering from parasitic skin infec- 
tions, or in need of attention in case of accidents or emergency. 



6 THE SCHOOL NURSE. 

(6) Routine classroom inspection at frequent intervals for the pur- 
pose of detecting unreported or unnoticed cases of communicable 
disease, noting the hygienic conditions of the classrooms, including 
cleanhness, the seating of children, the temperature, the quality of 
ventilation, and the regulation of illumination from the standpoint 
of visual comfort. 

(c) Health instruction to pupils. 

(d) Health instruction to teachers. 

(e) Follow-up work. 

(/) Observation of the sanitary condition of the buildings and 
grounds. 

2. Special duties — 

(a) Physical inspection. 

(b) Special classes. 

(c) Open-air schools. 

(d) School clinics. 

B. WHEN A PART-TIME PHYSICIxiN IS EMPLOYED. 

In schools having a volunteer medical service or service of a school 
physician on part-time basis, in addition to the routine duties out- 
lined, the nurse may properly engage in special work imder the phy- 
sician's direction, with special attention to preliminary physical 
inspection for detecting the more obvious physical defects and refer- 
ring handicapped cliildren to the school physician for confirmation 
of the diagnosis and advice regarding the treatment needed. 

' Rural School Nursing. 

Rural school nursing is quite a different proposition from that of 
nursing in urban schools and is surrounded by many difficulties. Of 
these may be mentioned the lack of nursing supervision, skilled medi- 
cal assistance, and of hospital and clinical facilities. Furthermore, 
at the present time, by reason of the nation-wide interest in child 
health work, the demand for school nurses in rural districts is greater 
than the supply, and a number of earnest workers are attempting 
school nursing with but limited training and experience in this spe- 
cial field. 

In a number of rural districts not only will the nurse be required to 
perform all of the general duties prescribed for a nurse of a school sys- 
tem having a full-time or part-time physician, but in many instances 
she will be called upon to act as a representative of the State health 
officer in so far as her work relates to the control of communicable 
diseases in the school, and to give instruction to posture and nutri- 
tion classes and in health education. 



THE SCHOOL NUESE. 7 

A. GENERAL CONSIDERATION. 

1. Contacts. — On first taking charge of the work m a given county 
or district the nurse should — 

(a) Make contacts with the county and local health officers, if 
there are such, to secure their cooperation, and arrange for the corre- 
lation of the school health work with the other health activities in 
the district. 

(&) Familiarize herself with the State laws and local ordinances 
relating to the control of communicable diseases and the medical 
inspection of schools and be governed accordingly. 

(c) Establish a friendly and confidential understanding with the 
local physicians and other influential citizens, business clubs, women's 
clubs, and representatives of the welfare agencies working in the 
district. 

A community-wide sentiment in favor of school health supervision 
is necessary for permanent good. As the work expands volunteer 
assistance will be needed in the solution of problems that can not be 
financed by the constituted authorities or by one individual or agency 
alone. 

2. Preliminary survey. — A rapid survey of each school in the dis- 
trict should be made to note the number and location, the facilities 
for carrying on the nursing work, the enrollment and average daily 
attendance, the hours for opening and closmg for the day, the num- 
ber and arrangement of the classes, the teaching methods, and the 
cooperation that may be expected of the teaching staff. 

3. Schedule of visits. — In order to accomplish the most work with 
the expenditure of a given amount of effort in a prescribed period of 
time, the school nurse must systematize her work as greatly as pos- 
sible. She should prepare a schedule of visits to the several schools 
under her charge, so that teachers, pupils, and parents always may 
know in advance the day and the hour the nurse will arrive at a 
given school for weighing and measuring, for physical inspection, for 
special class work, for health instruction, for conference with parents, 
or for other purposes. 

4. Hours on duty. — ^In general, the hour of opening school should 
find the nm-se at her post of duty prepared for the work of the day. 
No hard and fast rules can be laid down regarding the number of 
hours she should remain on duty. These must be determined by 
local conditions and by the necessities of different situations. The 
conscientious school nurse is more likely than otherwise to work too 
many hours each day. The duties of a rural school nurse are ardu- 
ous, and she should be careful to maintain uniform working schedule 
for each day in order to conserve her strength. Otherwise the work 
will suffer in the end. 



O THE SCHOOL NUBSE. 

B. ROUTINE WORK. 

As a rule the morning hours of each school day should be devoted 
to routme work, and the afternoons and Saturda3'-3 to special classes, 
health instruction, and follow-up work. However, if tJae attendance 
is small and the routine work in a given school does not require all 
of the nurse's time, special work should be arranged for the morning 
hours as well, and the whole of the afternoon given to outside work. 

1. Classroom inspection. — Immediately following the opening exer- 
cises the nurse should make a routine mspection of each classroom to 
discover incipient cases of communicable diseases, unrecognized cases 
of communicable diseases, undetected hampering defects, to note 
hygienic conditions, and to advise with teachers regarding conditions 
in need of immediate attention. 

2. Special inspection. — On completion of the classroom inspection, 
the nurse should repair to a room reserved for the purpose for a more 
thorough inspection of children — 

(a) Referred by the principal or teacher. 

{h) New entrants. 

(c) Returning after an absence of two or more days. 

{d) Referred for special attention at classroom inspection. 

(e) Consultation with parents. 

3. Physical inspection. — It is an unfortunate circumstance that 
makes it necessary for a school nurse to examine for physical defects. 
A& a rule the school nurse should not be required to make such 
inspection, because, strictly speaking, the detection and correction 
of physical defects should be considered a side issue in school health 
work, and prevention the mam object in view. The preventive side 
of school medical inspection requires greater technical training than 
that of the average nurse. Moreover, her other duties are sufficient 
to occupy all of her time and have, in addition, greater value from 
the standpoint of health protection and promotion. However, for a 
long time to come, physical inspections must be made by school 
nurses or by teachers, in the majority of the rural districts, if they 
are to be made at all. 

It is desirable that the inspection for the detection of physical 
defects should be made as near the beginning of the school year as 
possible, on a day or days designated for the purpose. The teaching 
staff should assist in this inspection. The parents should be notified 
of the impendmg inspection m advance, invited to be present, and 
their consent obtained to making the exammation. 

When it is impracticable to secure the consent or cooperation of 
the school authorities in setting aside a special day for inspection 
purposes, the nurse should inspect as many children as possible on 



THE SCHOOL NUESE. 9 

her regular visiting day to the schools, beginning with the primary 
grades. 

(a) Defects : The special conditions which should be looked for and 
recorded during physical inspections are as follows: 

(1) Defective vision. 

(2) Defective hearing. 

(3) Decayed and defective teeth. 

(4) Defective nasal breathing (mouth breathing). 

(5) Enlarged lymph glands (specify). 

(6) Enlarged tonsils. 

(7) Deformities. 

(8) Undernourishment. 

(9) Suspected tuberculosis (chronic cough, underweight, 

pallor). 
(10) Nervousness. 

Hearing should be recorded in terms of tenths of the normal 
distance at which the ticking of a watch or whispered speech may be 
heard. The watch used for this purpose should first be tested to 
determine the distance at which it can be heard by one with normal 
hearing. For example: If this distance should be 30 inches, it would 
be recorded as 10/10. If a child could hear the watch at a distance 
of 15 inches only, namely, 15/30, this would be recorded as 5/10. 
Each ear should be tested separately, the nurse standing behind the 
pupil, who should keep one ear covered with the hand and the eyes 
closed during the test. Do not introduce a finger into the ear canal 
to prevent hearing. 

Vision should be recorded in tenths of the normal distance (Lowell 
chart is well adapted) in the case of each eye separately, first, without 
glasses in case glasses are used, and then with glasses. Lack of 
vision in either eye is recorded as 0/10. 

Vision charts should be placed in such position as to receive illumi- 
nation from one side, and never in such position that obliges the child 
to face a window while reading the chart. Visual tests should not 
be made on dark, cloudy days. 

Under this heading should be recorded all deformities, especially of 
the spine, all paralytic conditions, missing fingers, arm or leg, or any 
other defects not already recorded. 

In examining the teeth and tonsils, wooden tongue depressors 
should be used for each child. After using, they should be broken and 
plaeed in a proper receptacle and burned at the end of the day's 
inspection. 



10 THE SCHOOL NUBSE. 

On completion of the inspection, the parents should be notified in 
the case of children suffering from physical defects requiring atten- 
tion, using a form similar to the following: 

A recent physical inspection of 

indicates the following abnormal conditions: 

You are advised to take to your family physician, dentist, oculist, 

or to a dispensary, for ad\dce and treatment. 

(Signed) 

The notification should be followed by personal visits, especially 
when the results of notification are negative. 

(6) Inspection for contagious diseases: Due attention should be 
paid to the presence of contagious diseases and to parasitic skin 
infections while making physical inspections. However, the main 
rehance for the detection and control of these diseases in the school 
population must be placed on their discovery by routine and special 
inspections and exclusion during the period of incipiency, 

i. Exclusion — Children found presenting symptoms of the following 
contagious diseases should be excluded from school: 

(a) Chicken pox. 

(b) Diphtheria. 

(c) Measles. 

(d) Mumps. 

(e) Scarlet fever. 
(/) Smallpox. 

(g) Open tuberculosis. 
(h) Whooping cough. 
Children found suffering from the following conditions should be 
referred to the family for treatment: 

(a) Acute eye infections. 

(b) Ringworm. 

(c) Scabies (itch). 

(d) Impetigo contagiosa. 

(e) Favus. 

In all cases of suspected diphtheria the nurse should secure a 
culture and forward it to the health authorities giving the name, age, 
and address of the child, and the name of the school. 

In handling cases of contagious diseases the nurse should be guided 
by the rules and regulations of the State and local boards of health. 

ii. Readmission — A child excluded from school on account of a 
quarantinable disease should not be readmitted to the school except 
on wi'itten statement of the health officer to the effect that he or 
she is no longer suffering from the disease in communicable form. 

In communities where there is no health officer, the child should 
not be readmitted to the school except on a similar written statement 



THE SCHOOL NURSE. 



11 



by the family physician and examination by the school physician, 
if there is one, or by the school nurse. 

4. WeigTiing and measuring. — Every child attending school should 
be weighed and measured at least twice during the school year, 
preferably at the time of the general inspection at the beginning of 
the school year, and again during the last month of the school year. 
Children found underweight according to available standards should 
be weighed at least once a month in order to determine whether 
improvement is taking place following advice. 

Children should be weighed and measured without shoes and with- 
out extra clothing. In the case of boys, the coat and vest should be 
removed before weighing. 

5. Nutrition classes. — Children found underweight should be or- 
ganized into nutrition classes for special instruction. The best 
results in nutrition work will be obtained if the mothers attend the 
nutrition classes to receive instruction in the causes and cure of 
undernourishment and give first-hand information of conditions in 
the home which act as contributing causes to the child's defective 
nourishment. 

(a) Causes : The following are some of the causes of undernourish- 
ment: 

(1) Insufficient food. 

(2) Improper food. 

(3) Irregular meals. 

(4) Bad eating habits (insufficient chewing). 

(5) Use of tea and coffee instead of milk. 

(6) Insufficient sleep. 

(7) Constipation. 

(8) Over excitement (motion pictures and evening enter- 

tainment) . 

(9) Endemic diseases, such as hookworm and malaria. 

(10) Physical defects, such as decayed teeth, diseased tonsils, 

and adenoids. 

(11) Too much school work. 

(12) Overwork before and after school hours. 

(13) Disturbance of endocrine system. 

In conducting nutrition classes, the nurse should give instruction 
with regard to the foods best adapted to promote the growth and 
development of children, and the reason why. In prescribing diets, 
mothers should not be instructed in terms of calory requirements, 
because the average mother will not readily understand and follow 
instructions given in such terms. The use of milk should be insisted 
upon, but not to the exclusion or limitation of other desirable food 
substances. 



12 THE SCHOOL NURSE. 

The results of the most scientifically prescribed diet will be de- 
stroyed without the correction of hampering physical defects, and of 
faulty conditions in the home, such as poor supervision, overwork, 
insufficient sleep, improper table habits, unhomelike atmosphere, 
insanitary home environment. 

A child 10 per cent underweight according to standard should be 
classified as undernourished in the sense that it indicates that the 
child should receive a very thorough physical examination by a 
competent physician to determine the underlying physical cause, 
if any, responsible for his condition. 

(b) School lunch: An important and often overlooked feature of 
school nutrition work is the school lunch. Where it is impossible or 
impracticable to serve hot lunches in the school, the nurse should 
instruct the children and their parents in the preparation of a desir- 
able school lunch. Too frequently the lunch of the school child 
consists largely of pie, cake, and other nonessential and indigestible 
food substances. 

6. Posture classes. — In schools without physical training courses, 
the school nurse can, with advantage, hold posture classes for children 
of weakened musculature with tendency to spinal curvature or othei* 
deformity. Such classes should be composed of children discovered 
on inspection who hold themselves in bad position, who have marked 
round shoulders or lateral curvature of the spine and other functional 
deformities, and children referred by the teacher who habitually 
assume a sprawling attitude while seated in the classroom and who 
appear easily fatigued. 

7. Follow up. — In a recent study of sicloiess and school absences 
among school children by the United States Public Health Service,^ 
it was shown in the case of 6,099 school children with 666,449 possible 
number of days of school attendance for one year, that 5.6 per cent 
or 37,321 days, were lost on account of sicloiess, and 3 per cent, or 
19,993 days, were lost on account of other causes. These figures are 
cited to show the relatively great iniportance of follow-up work as 
compared with the other duties of a school nurse. Not only is it 
possible for the nurse by mstruction in personal and home hygiene, 
care of the sick, and in the care and preparation of food, to shorten 
the duration of the absence from sickness in individual instances, 
but also reduce the number of cases of sickness arising during the 
year and the number of absences from causes other than sickness. 

Follow-up work is required for the purpose of — 

(a) Explaining the nature of notified physical and mental handi- 
caps, the effect thereof on the child's health, school progress, and 
economic efficiency, and the proper remedy. 

2 Sickness among school children— Loss of time from school among 6,130 school children in 13 localities 
in Missouri. By Selwyn D. Collins. Public Health Reports, July 8, 1921. Reprint No. 674. 



THE SCHOOL ISTUKSE. 13 

(h) Explaining the nature of the quarantinable diseases and the 
necessity and importance of the strict observance of quarantine for 
the protection of the community and of other members of the family. 

(c) Inquiring into the presence of open tuberculosis in the home in 
the case of children suspected of having tuberculosis. 

id) Inquiring into absences of more than two days' duration from 
unexplained causes. 

(e) Securing the cooperation of the parents in health instruction 
and enforcing in the home the regimen prescribed for children in 
special classes and schools. 

(/) Distributing pertinent health literature prepared or approved 
by the State and local health departments. 

(g) Securing the cooperation of the parents in practicing in the 
home the principles of health protection and promotion taught by 
health instruction in the regular and special classes and special 
schools. 

8. Health instruction. — To be effective, health instruction should 
be made a part of the school curriculum. However, in the absence 
of such an arrangement, the school nurse should interest the teacher 
in giving health instruction and help her to select suitable subjects 
and to secure reliable health education material. 

The nurse should realize that in the majority of instances the 
teacher herself is in need of health instruction. For this reason she 
should take advantage of teachers' institutes and arrange special 
occasions for the health instruction of the teachers in her district. 
The nurse should also impress the teacher with the importance of her 
own personal appearance and conduct and the effect thereof on the 
health habits of her pupils. She should tactfully advise regarding 
the health value of a neat personal appearance and the strict observ- 
ance of personal hygiene in the formation of proper health habits by 
her charges. 

Fundamentally, health instruction of cliildren consists largely in 
the cultivation of good health habits, in instruction regarding the 
underlying prinicples of health-promoting measures and the causes and 
control of communicable diseases, and in creating a sense of responsi- 
bility to the commiunity, not only from the standpoint of the observ- 
ance of the principles of personal hygiene individually but also from 
that of supporting measures for maintaining the community health. 

Health instruction of cliildren should comprise: 

(a) Giving health talks: The nurse should take advantage of the 
opportunity of contact with individual children in routine school 
work to impart individualized instruction. At the beginning of the 
school year she should confer with the school principal and teachers 



14 THE SCHOOL NURSE. 

in regard to health talks. These should vary with the grade visited. 
Some of the subjects that may be covered are as follows: 

(1) Fresh air — both night and day. 

(2) Proper amount of rest and sleep. 

(3) Food values, emphasizing effects of too much tea and 

coffee. 

(4) Mastication of food. 

(5) Correct posture and deep breathing. 

(6) Care of the body, special care of the hair, nails, teeth, and 

skin. 

(7) Prevention of colds. 

(8) Proper use of the handkerchief. 

(9) Proper clothing. 

(10) The communicable diseases, and how they are spread. 

(11) Disinfection. 

(12) Tonsils and adenoids. 

(13) Tuberculosis. 

(14) Vaccination. 

(15) Quarantine. 

(16) General hygiene. 

(h) Cultivating health liabits through— 

(1) Toothbrush drills. 

(2) The use of handkerchief. 

(3) Washing the hands, and baths. 

(4) Attention to the bowels. 

(5) Maintaining correct posture. 

(6) Securing sufficient rest and sleep. 
(c) Organization of school health clubs. 

{d) Preparing posters, compositions, and other health education 
material by the children. 

(e) Cooperating with the parents by — 

(1) Consultation at school. 

(2) Visits to the home. 

9. Observation of the sanitary condition of school huildings and 
grounds. — It is desirable that the rural school nurse shall have had 
some previous instruction in the sanitary requirements of school 
buildings and school grounds, because in schools where no physician 
is employed she can accomplish a very great good by giving advice to 
school principals and school boards regarding insanitary conditions in 
the school environment which should be corrected. 

Due attention should be paid to the proximity of nuisances which 
may be abated, the protection of the water supply from surface 
drainage, the location of privies in respect of drainage planes to avoid 
pollution of the water supply, the use of the common drinking cup 



THE SCHOOL ISTUESE, 15 

and the substitution of bubbling fountains therefor, the facihties for 
washing the hands, the provision of cloak and lunch rooms and their 
cleanliness, the condition of the heating plant and the efficiency of 
the ventilation system, the tinting of the classroom walls and the 
seating of children from the standpoint of maximum illumination 
with the least visual discomfort, and the condition of the school 
grounds from the standpoint of adequate play space, drainage, and 
walks. 

10. Records. — The nurse should keep accurate records of her work, 
which at all times should be available for the information of the health 
and educational authorities. Special forms should be used for record- 
ing the results of inspection, for recording follow-up work, for use in 
connection with the control of communicable diseases, and other 
forms as the necessity of them arises by reason of local conditions or 
requirements. 



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